Doctor Knows Best?

Does Judaism grant patient autonomy in medical decision-making?

While the Jewish world has the Torah from which to seek guidance, the secular world must rely on consensus. As a result, any society-wide decision must be widely inclusive of almost all philosophies, preferences, and religious beliefs. As there is very little that we all agree upon, very little can be legitimately circumscribed without infringing on the personal freedoms of someone individual or group.

So, when it comes to medical ethics, and particularly medical decision-making, secular society treads very lightly in compelling individuals to accept any particular treatment. The days of the physician knowing best and the patient blindly acquiescing are over. Instead, the modern approach to medical ethics is predicated upon several universalistic principles.

Secular society demands several things from physicians: that any health-care decision promoted by the physician be in the patient's best interests (beneficence); that the physician "do no harm" (non-maleficence); and that health-care be provided in a fair and equitable way to all, without prejudice (justice). But these three requirements are dwarfed by the fourth -- that the patient has the ultimate responsibility and final decision-making capacity with respect to health-care decisions (autonomy).

The question naturally arises how a patient without medical training can exercise their autonomy if they do not understand the choices being placed before them. That is why one of the most important requirements in allowing for true patient autonomy is the concept of informed consent. The patient must be given enough information to allow for an educated and reasoned healthcare decision.

The usual secular understanding of informed consent is predicated upon the right of the individual to express his autonomy by deciding which actions he will or will not allow to be performed on his body.

There are those who would (incorrectly) argue that such a right is not compatible with Judaism, which tends to take a paternalistic view of human endeavors, including the practice of medicine.

The Torah states that man was created in the image of God and teaches that his body is the property of the Creator. Since a person is given only custodial rights to his body and charged with being the prudent steward of his body, it would seem, the argument goes, that he would be required to accept medical treatment. This would seem to preclude the possibility of there being a meaningful concept of informed consent in Jewish law. This would also seem to suggest that Jewish physicians could not ethically offer their patients treatment that they do not believe to be the optimal choice.

#Judaism requires a type of informed consent that is in some ways more stringent than its secular counterpart.
However this line of reasoning is not a correct description of the Jewish position! While the basis for the Torah approach may differ from that of secular society, Judaism does indeed require a type of informed consent that is in some ways more stringent than its secular counterpart.

The key distinction between the secular and the Jewish approaches to informed consent is the difference between rights and obligations. The secular emphasis on autonomy inescapably leads to the conclusion that the patient has the right to refuse any and all medical information. In Judaism, both becoming informed and giving consent for appropriate treatment are required. These requirements transform informed consent from a right into an obligation. From the patient's side, every person is obligated to actively guard his body and make medical decisions in a responsible way.

The Jewish patient's personal requirement of informed consent is akin to a money manager entrusted with the funds of a client. In this case, the client is God and the funds are the person's body. Just as the money manager must research all reasonable investment options before investing, so too the patient is obligated to investigate the medical options before acting. After accumulating the necessary information, the money manager MUST decide where to invest his client's money because that is his mandate. Only if he feels that all investment options are unacceptable for his client, based on sound reasoning, may he leave the money as cash.

Similarly, as the prudent stewards of our own bodies, we are mandated to acquaint ourselves with all reasonable medical options, including inaction, before making a decision. But after evaluating all reasonable options, the Torah requires us to choose the sensible option; i.e., the one that the prudent steward would choose.

The degree of autonomy that Judaism grants in any given case is directly related to the degree of certainty that exists among physicians regarding how a given illness should be evaluated and treated. Were medicine to be a monolith, with every problem having an obvious answer upon which all physicians agreed, then the individual would have little say in which medical treatments he wishes to have. All of the patient's research would necessarily lead to the same treatment option and he would be compelled to follow his physician's advice.

But in reality, most medical decisions are composed of multiple issues, including the social and psychological dimensions, each of which requiring evaluation and consultation. Only the most straight-forward problems have clear answers.

Some decisions are so obvious that the individual in reality has no choice. A person diagnosed with bacterial meningitis requires an antibiotic. Refusal to accept the medicine means almost certain death. The risk of ingesting the drug is only the very slim chance of a (usually treatable) allergic reaction. The prudent steward must accept the antibiotic once the medical reality is laid before him. If he refuses, Jewish law would allow us to coerce him to "voluntarily" consent to the treatment.

But how can coerced consent be valid? This is analogous to the reality of the American "voluntary" tax system that coerces one to voluntary fulfill his obligation to pay taxes.

But on a more fundamental level, we merely coerce him to fulfill his obligation of being the prudent steward. This concept is readily accepted by secular society. The concept that certain decisions are so irrational that society may step in and coerce the patient to pursue a specific course of action is well recognized within the mental health field and secular law. At some point, if a person is deemed to be a threat to themselves or others, they may be involuntarily committed to a mental hospital. A person who refuses antibiotic therapy for bacterial meningitis without a rational reason is a threat to themselves because they are not acting as a prudent steward in protecting their body from life-threatening illness

But what of the patient faced with hazardous surgery? There are many issues to be investigated and clarified before a judicious decision can be made. What are the possible risks? How long may the surgery be safely postponed? What is the expected outcome? Are there other reasonable options? Answering these questions represents the "informed" part of Jewish informed consent. But once all of the information has been gathered and assimilated, the patient must make a decision based on the facts presented to him.

Insight can be gained from a responsum written by Rabbi Moshe Feinstein, the leading halachic authority in the previous generation. He clearly accepted that patient input is crucial in medical decision-making. Only in cases where the treatment is obvious and unequivocal does he advocate coercion (though clearly not physical coercion). But in cases where the patient refuses treatment, he distinguishes between the patient who is afraid of the pain associated with efficacious treatment and the patient who does not trust the judgment of his doctor (Igros Moshe, Choshen Mishpat II:73e).

#The physician is obligated to explain his or her assessment of the various options, but the final steward mandated to make the correct decision is the patient.

The former patient, who recognizes the appropriateness of the treatment but fears the pain, should be convinced to fulfill his obligation to receive the appropriate therapy. For the latter patient who distrusts the medical advice that he has received, we must find a physician whom the patient trusts in order to receive the patient's consent. This is because for the patient to properly perform his role as prudent steward of his own body, he must be convinced that the information that he has been given is accurate. This distinction drives home the concept that one is required to accept the rational therapy, but may refuse treatment until he is convinced that the proposed course of treatment is prudent.

We see from here that the physician is part of the Jewish consent process. The physician must provide the full range of options because the patient is the one who ultimately must decide on the proper course of action. The physician is certainly obligated to explain his or her assessment of the various options, but the final steward mandated to make the correct decision is the patient, not the doctor.

The constraints that Judaism places on informed consent are the same as those which it places on the rest of Jewish life. Judaism requires intellectual honesty in evaluating all options in life. One is required to honestly evaluate the options before him and make a decision based on logic, self-awareness, and Torah. Far from placing Judaism outside the pale of the "modern" approach to the physician-patient relationship, these principles should make us a model for those who desire a rational approach to the difficult area of medical decision-making.

Related Articles:

About the Author

Dr. Daniel Eisenberg is with the Department of Radiology at the Albert Einstein Medical Center in Philadelphia, PA and an Assistant Professor of Diagnostic Imaging at Thomas Jefferson University School of Medicine. He has taught a Jewish medical ethics class for the past 15 years. Dr. Eisenberg writes extensively on topics of Judaism and medicine and lectures internationally on topics in Jewish medical ethics to groups of all backgrounds. Obtain more information on scheduling a lecture or learning more about Jewish medical ethics by visiting Dr. Eisenberg at www.daneisenberg.com

Visitor Comments: 4

(4)
Anonymous,
March 25, 2009 10:02 AM

physicians' responsibility?

I see clearly the responsibility of the patient in this article. It is the patient’s responsibility to take care of his body and to make sure that he is making correct decisions regarding it. This is part of living a Jewish life, a life with God and His torah at the center. I see that the physician has a responsibility here too- to provide the best information for the patient and guide him to making these correct decisions. I wonder though if the physician (Jewish physician) doesn't have any further responsibility. We accept to a degree the concept of "don't stand idly by" you yourself explain that a physician who can heal but doesn't is in violation of "Do not kill". With regards to a patient who will not make what the doctor deems a correct decision about his health, what are the responsibilities and options of the doctor? Is the doctor obligated in any way (according to halakha) to treat the patient regardless (an obligation which he can clearly not fulfill) or has he fulfilled his obligation by educating the patient to the best of his ability. How does one balance the physician’s obligation to heal and the patient’s obligation (and right) to make correct decisions about his body and health when the two parties feel strongly in opposite directions?

(3)
Tina Kingberg,
March 30, 2006 12:00 AM

Ethics of the Doctors

One had better be sure to choose a Torah observant doctor or one who is a "G-d fearer" from among the Gentiles in America today. The indoctrination of young doctors into the darwinian "science is all truth" lie and the general decline of morality, religion and ethics today, make putting that much faith in any professional a really risky business. As Jews, part of the ethic we are to follow regarding our bodies includes not taking unnecessary risks. With the Insurance industry running doctors' practices and requiring almost assembly line processing of patients, most of us are given short shrift, particularly if we don't present in classical textbook fashion. Women especially are too frequently dismissed as being neurotic, depressed or just plain crazy. The drug companies provide the instant gratification solutions Americans want; "here thake this pill." We treat symptoms but don't cure illness or CARE for the whole person. In my case, Medicaid would glaadly pay the tens fo thousands it would cost to "stablilize" my spine but they'll only give me 24 visits a year to a chiropractor even tho, it's pretty well accepted that chiropractic is more beneficial in spinal disorders especially BEFORE it's too late and the spinal vertebrae and discs disintegrate completely.
In short, there is very little ethical practice in American medicine today as well as an increase in materialism and decrease in spiritual practice of any sort. The non-spiritual among us just do not respond to our ethical stands. Sometimes all we can do is move on. This is why I say if one wants to be an Observant Jew in the matter of one's health, one had better find a doctor who has a similar outlook. Worldly credentials mean nothing. I believe the professional who prays, and commits him/hersef to providing G-dly care will have the superior credentials and we need not worry about where the diploma was printed.

(2)
Alan Israel,
July 2, 2004 12:00 AM

This is the way our medical office does things.

I was very pleased to read an article that my head kept bouncing up and down. I work for a non-jewish Ophthalmologist that actually subscribes to the Jewish way of practicing of medicine. I wish more people would pay attention to the words of this article. It is ALWAYS ultimately the decision of the patient, and they should ALWAYS be informed not only of the risks and benefits, but also the alternitives.

(1)
Anonymous,
February 8, 2004 12:00 AM

A deep feeling

I appreciated this article, particularly
because our family is living a difficult situation: my daughter´s mother -in-law found out that she has a breast cancer and has to remove one of her breasts. She is not jewish, but she trusts her medical advice and she is hopeful, as all of us are, despite the sadness os the situation. She is very young, only 43! We have two beautiful grandsons, a girl and a newly-born boy.
I pray to God that she wins this disease
and that we can see, together, our grandsons grow.
Thank you for this opportunity to write about these difficult feelings.
I have always thought that we are responsible for our good health and your article gave support in the Torah
for my beliefs. I have been educated in
a religious jewish school, in Brazil, and I believe in God. I know that he will be looking for her.

Thanks
Miriam Grossman Menascé

Submit Your Comment:

Name:*

Display my name?

YesNo

Email:*

Your email address is kept private. Our editor needs it in case we have a question about your comment.

I'm told that it's a mitzvah to become intoxicated on Purim. This puzzles me, because to my understanding, it is not considered a good thing to become intoxicated, period.

One of the characteristics of the at-risk youth is their use of drugs, including alcohol. In my experience, getting drunk doesn't reveal secrets. It makes people act stupid and irresponsible, doing things they would never do if they were sober. Also, I know a lot about the horrible health effects of abusing alcohol, because I work at a research center that focuses on addiction and substance abuse.

Also, I am an alcoholic, which means that if I drink, very bad things happen. I have not had a drink in 22 years, and I have no intention of starting now. Surely there must be instances where a person is excused from the obligation to drink. I don't see how Judaism could ever promote the idea of getting drunk. It just doesn't seem right.

The Aish Rabbi Replies:

Putting aside for a moment all the spiritual and philosophical reasons for getting drunk on Purim, this remains an issue of common sense. Of course, teenagers should be warned of the dangers of acute alcohol ingestion. Of course, nobody should drink and drive. Of course, nobody should become so drunk to the point of negligence in performing mitzvot. And of course, a recovering alcoholic should not partake of alcohol on Purim.

Indeed, the Code of Jewish Law explicitly says that if one suspects the drinking may affect him negatively, then he should NOT drink.

Getting drunk on Purim is actually one of the most difficult mitzvot to do correctly. A person should only drink if it will lead to positive spiritual results - e.g. under the loosening affect of the alcohol, greater awareness will surface of the love for God and Torah found deep in the heart. (Perhaps if we were on a higher spiritual level, we wouldn't need to get drunk!)

Yet the Talmud still speaks of an obligation on Purim of "not knowing the difference between Blessed is Mordechai and Cursed is Haman." How then should a person who doesn't drink get the point of “not knowing”? Simple - just go to sleep! (Rama - OC 695:2)

All this applies to individuals. But the question remains - does drinking on Purim adversely affect the collective social health of the Jewish community?

The aversion to alcoholism is engrained into Jewish consciousness from a number of Biblical and Talmudic sources. There are the rebuking words of prophets - Isaiah 28:1, Hosea 3:1 with Rashi, and Amos 6:6, and the Zohar says that "The wicked stray after wine" (Midrash Ne'alam Parshat Vayera).

It is well known that the rate of alcoholism among Jews has historically been very low. Numerous medical, psychological and sociological studies have confirmed this. The connection between Judaism and sobriety is so evident, that the following conversation is reported by Lawrence Kelemen in "Permission to Receive":

When Dr. Mark Keller, editor of the Quarterly Journal of Studies on Alcohol, commented that "practically all Jews do drink, and yet all the world knows that Jews hardly ever become alcoholics," his colleague, Dr. Howard Haggard, director of Yale's Laboratory of Applied Physiology, jokingly proposed converting alcoholics to the Jewish religion in order to immerse them in a culture with healthy attitudes toward drinking!

Perhaps we could suggest that it is precisely because of the use of alcohol in traditional ceremonies (Kiddush, Bris, Purim, etc.), that Jews experience such low rates of alcoholism. This ceremonial usage may actually act like an inoculation - i.e. injecting a safe amount that keeps the disease away.

Of course, as we said earlier, all this needs to be monitored with good common sense. Yet in my personal experience - having been in the company of Torah scholars who were totally drunk on Purim - they acted with extreme gentleness and joy. Amid the Jewish songs and beautiful words of Torah, every year the event is, for me, very special.

Adar 12 marks the dedication of Herod's renovations on the second Holy Temple in Jerusalem in 11 BCE. Herod was king of Judea in the first century BCE who constructed grand projects like the fortresses at Masada and Herodium, the city of Caesarea, and fortifications around the old city of Jerusalem. The most ambitious of Herod's projects was the re-building of the Temple, which was in disrepair after standing over 300 years. Herod's renovations included a huge man-made platform that remains today the largest man-made platform in the world. It took 10,000 men 10 years just to build the retaining walls around the Temple Mount; the Western Wall that we know today is part of that retaining wall. The Temple itself was a phenomenal site, covered in gold and marble. As the Talmud says, "He who has not seen Herod's building, has never in his life seen a truly grand building."

Some people gauge the value of themselves by what they own. But in reality, the entire concept of ownership of possessions is based on an illusion. When you obtain a material object, it does not become part of you. Ownership is merely your right to use specific objects whenever you wish.

How unfortunate is the person who has an ambition to cleave to something impossible to cleave to! Such a person will not obtain what he desires and will experience suffering.

Fortunate is the person whose ambition it is to acquire personal growth that is independent of external factors. Such a person will lead a happy and rewarding life.

With exercising patience you could have saved yourself 400 zuzim (Berachos 20a).

This Talmudic proverb arose from a case where someone was fined 400 zuzim because he acted in undue haste and insulted some one.

I was once pulling into a parking lot. Since I was a bit late for an important appointment, I was terribly annoyed that the lead car in the procession was creeping at a snail's pace. The driver immediately in front of me was showing his impatience by sounding his horn. In my aggravation, I wanted to join him, but I saw no real purpose in adding to the cacophony.

When the lead driver finally pulled into a parking space, I saw a wheelchair symbol on his rear license plate. He was handicapped and was obviously in need of the nearest parking space. I felt bad that I had harbored such hostile feelings about him, but was gratified that I had not sounded my horn, because then I would really have felt guilty for my lack of consideration.

This incident has helped me to delay my reactions to other frustrating situations until I have more time to evaluate all the circumstances. My motives do not stem from lofty principles, but from my desire to avoid having to feel guilt and remorse for having been foolish or inconsiderate.

Today I shall...

try to withhold impulsive reaction, bearing in mind that a hasty act performed without full knowledge of all the circumstances may cause me much distress.

With stories and insights,
Rabbi Twerski's new book Twerski on Machzor makes Rosh Hashanah prayers more meaningful. Click here to order...